Medicare Benefits Schedule

When paying the reasonable costs of medical services, the TAC and WorkSafe pay in line with the Medicare Benefits Schedule (MBS) items, explanations, definitions, rules and conditions, unless otherwise specified in the TAC or WorkSafe policies or the relevant Reimbursement Rates for Medical Services publication.

This information sheet clarifies what the TAC and WorkSafe can and cannot pay for in relation to a number of specific MBS item combinations.

1. Billing of MBS item 30111 in combination with 48948, 48951, 48954, 48957 or 48960

Descriptions from MBS:

-        30111 – BURSA (LARGE), INCLUDING OLECRANON, CALCANEUM OR PATELLA, excision of

-        48948 – SHOULDER, arthroscopic surgery of, involving any 1 or more of: removal of loose bodies; decompression of calcium deposit; debridement of labrum, synovium or rotator cuff; or chondroplasty- not being a service associated with any other arthroscopic procedure of the shoulder region

-        48951 – SHOULDER, arthroscopic division of coraco-acromialligament including acromioplasty - not being a service associated with any other arthroscopic procedure of the shoulder region

-        48954 – SHOULDER, arthroscopic total synovectomy of, including release of contracture when performed

-        not being a service associated with any other arthroscopic procedure of the shoulder region

-        48957 – SHOULDER, arthroscopic stabilisation of, for recurrent instability, including IabraI repair or reattachment when performed -not being a service associated with any other arthroscopic procedure of the shoulder region

-        48960 – SHOULDER, reconstruction or repair of, including repair of rotator cuff by arthroscopic, arthroscopic assisted or mini open means; arthroscopic acromioplasty; or resection of acromioclavicular joint by separate approach when performed- not being a service associated with any other procedure of the shoulder region

What the TAC or WorkSafe can and cannot pay

Benefit is payable for item 30111 when billed in combination with item 48948, 48951, 48954, 48957 or 48960 where there is clinical indication for formal bursectomy and the procedure is undertaken and described in the operation report.

TAC and WorkSafe do not expect that formal bursectomy would be required and undertaken in all cases.

2. Billing of MBS items 40330 and 45018

Descriptions from MBS:

-        40330 – SPINAL RHIZOLYSIS involving exposure of spinal nerve roots – for lateral recess, exit foraminal stenosis, adhesive radiculopathy or extensive epidural fibrosis, at 1 or more levels – with or without partial or total laminectomy

-        45018 – DERMIS, DERMOFAT OR FASCIA GRAFT (excluding transfer of fat by injection

What the TAC or WorkSafe can and cannot pay

No benefit is payable for item 45018 when billed in combination with item 40330.

The TAC and WorkSafe do not consider the simple placing of fat, locally harvested, to satisfy the requirement for payment of 45018.

3. Billing of MBS items 40330 and items 40300, 40303 or 40306 Descriptions from MBS:

-        40330 – SPINAL RHIZOLYSIS involving exposure of spinal nerve roots – for lateral recess, exit foraminal stenosis, adhesive radiculopathy or extensive epidural fibrosis, at 1 or more levels – with or without partial or total laminectomy

-        40300 – INTERVERTEBRAL DISC OR DISCS, partial or total laminectomy for removal of

-        40303 – RECURRENT DISC LESION OR SPINAL STENOSIS, or both, partial or total laminectomy for – 1 level

-        40306 – SPINAL STENOSIS, partial or total laminectomy for, involving more than 1 vertebral interspace (disc level)

What the TAC or WorkSafe can and cannot pay

Benefit is payable for item 40330 when billed in combination with item 40300, 40303 or 40306, where the rhizolysis is indicated as an independent procedure, there is a specific clinical indication and the surgical exploration and decompression of the lateral/foraminal recess is undertaken, in addition to a laminectomy.

4. Billing of MBS items 30023 and 48400 to 48427 with fracture items (47300 to 47789)

Descriptions and relevant explanatory notes from MBS:

-        30023 – WOUND OF SOFT TISSUE, traumatic, deep or extensively contaminated, debridement of, under general anaesthesia or regional or field nerve block, including suturing of that wound when performed.

Explanatory note T.8.7. For the purposes of items 30026 and 30049 the term 'superficial' means affecting skin and subcutaneous tissue including fat and the term 'deeper tissue' means all tissues deep to but not including subcutaneous tissue such as fascia and muscle. These items do not cover repair of wound at time of surgery. Item 30023 covers debridement of traumatic, "deep and extensively contaminated" wound. Benefits are not payable under this item for debridement which would be expected to be encountered as part of an operative approach to the treatment of fractures especially if the fracture is compound.

-        48400 – PHALANX, METATARSAL, ACCESSORY BONE OR SESAMOID BONE, osteotomy or osteectomy of, excluding services to which item 49848 or 49851 applies, any of items 49848, 49851,

-        47933 or 47936 apply

-        48403 – PHALANX OR METATARSAL, osteotomy or osteectomy of, with internal fixation, and excluding services to which items 47933 or 47936 apply

-        48406 – FIBULA, RADIUS, ULNA, CLAVICLE, SCAPULA (other than acromion), RIB, TARSUS OR CARPUS, osteotomy or osteectomy of, excluding services to which items 47933 or 47936 apply

-        48409 – FIBULA, RADIUS, ULNA, CLAVICLE, SCAPULA (other than Acromion), RIB, TARSUS OR CARPUS, osteotomy or osteectomy of, with internal fixation, and excluding services to which items

-        47933 or 47936 apply

-        48412 – HUMERUS, osteotomy or osteectomy of, excluding services to which items 47933 or 47936 apply

-        48415 – HUMERUS, osteotomy or osteectomy of, with internal fixation, and excluding services to which items 47933 or 47936 apply

-        48418 – TIBIA, osteotomy or osteectomy of, excluding services to which items 47933 or 47936 apply

-        48421 – TIBIA, osteotomy or osteectomy of, with internal fixation, and excluding services to which items

-        47933 or 47936 apply

-        48424 – FEMUR OR PELVIS, osteotomy or osteectomy of, excluding services to which items 47933 or 47936 apply

-        48427 – FEMUR OR PELVIS, osteotomy or osteectomy of, with internal fixation, and excluding services to which items 47933 or 47936 apply

-        Fracture items (47300 to 47789)

Explanatory note T.8.116. Open reduction means treatment of a dislocation or fracture by either operative exposure including the use of any internal or external fixation; or non-operative (closed reduction) where intra-medullary or external fixation is used.

 

What the TAC or WorkSafe can and cannot pay

4a   Item 30023 in combination with fractures (47300 to 47789)

Benefit is payable for 30023 when billed in combination with any fracture item where the wound is separate to the operative approach to the treatment of the fracture.

The TAC and WorkSafe expect that 30023 be used once for the definitive debridement of the wound, and description should include location, dimensions and nature of the wound.

4b   Items 48400 to 48427 in combination with fractures (47300 to 47789)

No benefit is payable for items 48400 to 48427 in combination with fracture items.

In exceptional circumstances benefit may be payable, the invoice needs to note 'exceptional circumstance' and include a brief description, such as:

(a)   significant amount of bone removed to shorten acutely; or planned amount of bone removal (via osteotome or saw not just with 'dissection') to correct a deformity, eg in a malunited fracture.

(b)  planned amount of bone removal (via osteotome or saw not just with 'dissection') to correct a deformity, eg in a malunited fracture.

5. Billing of MBS item 30023 in the context of the primary surgical wound

Descriptions and relevant explanatory notes from MBS:

-        30023 – WOUND OF SOFT TISSUE, traumatic, deep or extensively contaminated, debridement of, under general anaesthesia or regional or field nerve block, including suturing of that wound when performed.

Explanatory note T.8.7. For the purposes of items 30026 and 30049 the term 'superficial' means affecting skin and subcutaneous tissue including fat and the term 'deeper tissue' means all tissues deep to but not including subcutaneous tissue such as fascia and muscle. These items do not cover repair of wound at time of surgery. Item 30023 covers debridement of traumatic, "deep and extensively contaminated" wound. Benefits are not payable under this item for debridement which would be expected to be encountered as part of an operative approach to the treatment of fractures especially if the fracture is compound.

 

What the TAC or WorkSafe can and cannot pay

Benefit is payable for item 30023 where the wound is separate to the operative approach for the primary surgical procedure.

Subsequent inspections or dressings or simple closure of a wound are more adequately described under other MBS item numbers.

The TAC and WorkSafe consider repair of the surgical incision to be part of the elective procedure.

The TAC and WorkSafe do not consider washout of a wound; repair of a superficial or non-contaminated wound; or repair of a primary surgical incision to satisfy the requirement for billing 30023.

6. Multiple billing of MBS item 30023

Descriptions and relevant explanatory notes from MBS:

-        30023 – WOUND OF SOFT TISSUE, traumatic, deep or extensively contaminated, debridement of, under general anaesthesia or regional or field nerve block, including suturing of that wound when performed.

Explanatory note T.8.7. For the purposes of items 30026 and 30049 the term 'superficial' means affecting skin and subcutaneous tissue including fat and the term 'deeper tissue' means all tissues deep to but not including subcutaneous tissue such as fascia and muscle. These items do not cover repair of wound at time of surgery. Item 30023 covers debridement of traumatic, "deep and extensively contaminated" wound. Benefits are not payable under this item for debridement which would be expected to be encountered as part of an operative approach to the treatment of fractures especially if the fracture is compound.

 

What the TAC or WorkSafe can and cannot pay

Benefit is payable for multiples of item 30023. 

However, the TAG and WorkSafe expect that 30023 will be billed only once per individual wound debridement, regardless of size.

7. Application of MBS items 47729 and 47726

Descriptions from MBS:

-        47729 – BONE GRAFT, harvesting of, via separate incision, in conjunction with another service autogenous – large quantity

-        47726 – BONE GRAFT, harvesting of, via separate incision, in conjunction with another service – autogenous – small quantity

What the TAC or WorkSafe can and cannot pay

Benefit is payable for items 47729 and 47726 where the bone graft is harvested via a separate skin incision.

The TAC and WorkSafe expect the use of these items to reflect a 'stand–alone' procedure rather than being used where a bone graft is taken from an existing operative site.

8. Billing of MBS items 48684, 48654, 50106 and 40300 to 40306

Descriptions from MBS:

-        48684 – SPINE, segmental internal fixation of, other than for scoliosis, being a service associated with a service to which any 1 of items 48642 to 48675 applies – 1 or 2 levels, not being a service associated with artificial intervertebral total disc replacement

-        50106 – JOINT, stabilisation of, involving 1 or more of: repair of capsule, repair of ligament or internal fixation, not being a service to which another item in this Group applies

-        40300 – INTERVERTEBRAL DISC OR DISCS, partial or total laminectomy for removal of

-        40303 – RECURRENT DISC LESION OR SPINAL STENOSIS, or both, partial or total laminectomy for – 1 level

-        40306 – SPINAL STENOSIS, partial or total laminectomy for, involving more than 1 vertebral interspace (disc level)

-        48654 – SPINAL FUSION (posterior interbody), with partial or total laminectomy, 1 level

What the TAC or WorkSafe can and cannot pay

8a    Item 48654 in combination with 48684

Benefit is payable for item 48654 when billed in combination with 48684

8b    Item 50106 in combination with 48654

No benefit is payable for 50106 billed in combination with 48654, when 50106 relates to stabilisation at the level of the spinal fusion.

The TAC and WorkSafe consider the spinal fusion will incorporate joint stabilisation at that level.  If stabilisation is performed at a separate level, the invoice should note 'exceptional circumstance' and include a brief explanation.

8c    Item 40300 in combination wiyth 48654

Benefit is payable for items 40300 to 40306 when billed in conjunction with item 48654.

9. Multiple billing of MBS item 48639

Descriptions from MBS:

-        48639 – VERTEBRAL BODY, total or subtotal excision of, including bone grafting or other form of fixation

What the TAC or WorkSafe can and cannot pay

Benefit is payable for multiples of item 48639, when the total or subtotal excision is undertaken and clearly described in the operation report.

Benefit is not payable on this item when used in an elective surgery context, such as anterior spinal fusion.

10. Billing of MBS items 160 to 164

Descriptions and relevant explanatory notes from MBS: Prolonged professional attendances

The conditions to be met before services covered by items 160 to 164 attract benefits are:

(i)         the patient must be in imminent danger of death;

(ii)       the constant presence of the medical practitioner must be necessary for the treatment to be maintained; and

(iii)   the attention rendered in that period must be to the exclusion of all other patients.

-        160 – For a period of not less than 1 hour but less than 2 hours

-        161 – For a period of not less than 2 hours but less than 3 hours

-        162 – For a period of not less than 3 hours but less than 4 hours

-        163 – For a period of not less than 4 hours but less than 5 hours

-        164 – For a period of 5 hours or more

Explanatory note G.14.3. A consultation fee may only be charged if a consultation occurs: that is, it is not expected that consultation fees will be charged on every occasion a procedure is performed.

Where the level of benefit for an attendance depends upon the consultation time (for example, in psychiatry), the time spent in carrying out a procedure which is covered by another item in the MBS, may not be included in the consultation time.

What the TAC or WorkSafe can and cannot pay

Benefit is payable for any 1 of items 160 to 164, where all conditions for the use of the item number are met.

The time taken to perform concurrent procedures which are also invoiced must not be included in the consultation time.

11. Billing of MBS items 30168 and 30171

Descriptions from MBS:

-        30168 – LIPECTOMY wedge excision of skin and fat, not being a service associated with items 45564, 45565 or 45530 and not being a service to which item 30165 applies, 1 EXCISION

-        30171 – LIPECTOMY wedge excision of skin and fat, not being a service associated with items 45564, 45565 or 45530 and not being a service to which item 30165 applies, 2 OR MORE EXCISIONS

What the TAC or WorkSafe can and cannot pay

No benefit is payable for item 30168 or 30171 when billed in conjunction with any other surgical procedure. In exceptional circumstances, benefit may be payable, the invoice needs to note 'exceptional circumstance' and include a brief description, such as:

'Where there is clinical indication (eg for excision of fat necrosis), TAC and WorkSafe expect this to be undertaken and described in addition to the principal procedure. It is anticipated wedge excision of skin and fat would rarely be required and undertaken.'

12. Concurrent billing of MBS item 47702, 48684, 40300 to 40306 and 48600

Descriptions and relevant explanatory notes from MBS:

-        47702 – SPINE, treatment of fracture, dislocation or fracture–dislocation, with cord involvement, requiring open reduction with or without internal fixation, including up to 14 days post-operative care

-        Explanatory note T.8.116. Open reduction means treatment of a dislocation or fracture by either operative exposure including the use of any internal or external fixation; or non-operative (closed reduction) where intra-medullary or external fixation is used.

-        48684 – SPINE, segmental internal fixation of, other than for scoliosis, being a service associated with a service to which any one of items 48642 to 48675 applies – 1 or 2 levels, not being a service associated with artificial intervertebral total disc replacement

-        40300 – INTERVERTEBRAL DISC OR DISCS, partial or total laminectomy for removal of

-        40303 – RECURRENT DISC LESION OR SPINAL STENOSIS, or both, partial or total laminectomy for – 1 level

-        40306 – SPINAL STENOSIS, partial or total laminectomy for, involving more than 1 vertebral interspace (disc level)

-        48600 – SPINE, MANIPULATION OF, performed in the operating theatre of a hospital

What the TAC or WorkSafe can and cannot pay

12a        Billing of item 48684 in combination with 47702

Benefit is payable for item 48684 billed in combination with 47702.

12b        Billing of item 40300 to 40306 in combination with 47702

No benefit is payable for items 40300 to 40306 billed in combination with 47702, when 40300 to 40306 relates to the level of the spinal fracture, as this would be included as part of the fracture management at that level.

The TAC and WorkSafe do not anticipate that additional laminectomy would be required and undertaken in all cases; however, if a laminectomy is performed at a separate level, the invoice should note 'exceptional circumstance' and include a brief description.

12c         Billing of item 48600 in combination with 47702

No benefit is payable for item 48600 when billed in combination with any other procedure.

The TAC and WorkSafe consider item 48600, spine manipulation of, a 'stand-alone' item applied when manipulation under anaesthesia is the definitive treatment and thus not applied in combination with other spinal items.

13.    Billing of MBS item 50127

Description from MBS:
-    50127 – JOINT OR JOINTS, arthroplasty of, by any technique not being a service to which another item applies

What the TAC or WorkSafe can and cannot pay
The TAC and WorkSafe consider that item 50127 is an example of an item number that is not appropriate to invoice in surgery “to which another item applies”, according to the stated descriptor requirements. This includes situations where another item number applies but is chosen not to be utilised for that procedure.
For example, no benefit is payable for item 50127 in relation to orthopaedic shoulder surgical procedures, including those that involve shoulder arthroplasty, because the MBS provides items within the range of 48900-48960 that apply to these procedures.